HomeMy WebLinkAboutBLD-23-005168 ONE & TWO FAMILY ONLY- BUILDING PERMIT
Town of Yarmouth Building Department co 'y -.
1146 Route 28,South Yarmouth,MA 02664-4492
508-398-2231 ext. 1261 Fax 508-398-0836 '' 4
Massachusetts State Building Code,780 CMR ,t
Building Permit Application To Construct, Repair, Renovate Or Demolish
a One-or Two-Family Dwelling Rom`-
CEIvED
This Section For Official Use Only
Building Permit Number: A L I a 3- (V5//e Date Ai).i ,. M' ' 2 0 2913
\in JaP‘cD _/',, ��� V�� BUILDING DFP%RrMENT
Building Official(Print Name) • Signature
-_
SECTION 1:SITE INFORMATION
1.1 Property Addxess: a� , 1.2 Ass sons ap&Parcel Numbers Lot -1
� l� lkil�(1 K i✓ 2SbGl5er c
1.1 a Is this an accepted street?yes__AZ no Map Numbe Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard 1())-1tA (. Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 1 Private 0 Zone: _ Outside Flood Zone?Check if yes❑ Municipal 0 On site disposal system -14SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Tlpli n ,end jk.(�j -6ce('i11.i1 1� . `A010(Y1DUt ) Cl. o 2t4q
Name Trim)) City,State,Z
No.and Street Telephone ()Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied $,], Repairs(s) 0 Alteration(s) l( Addition 0
Demolition ❑ Accessory Bldg. 0 �#Number of Units Other 0 Specify:
Brief Descri+tion of Proposed Work': ALiU fafunkel 13 ear.
--- ? 10 0 U-, /,_,c1)(.4.(,,
SECTION 4:ESTIMATED CONSTRUCTION COSTS.
Estimated Costs:
Item ) Official Use Only V D
(Labor and Materials E ,
I.Building $ (� t �(} 1. Building Permit Fee:$ Indicate how fee is ec G
2.Electrical $ ill Standard City/Town Application Fee 2023- 0 Total Project Cq t3(Item 6)x multiplier x Ap'' 1 Q
3.Plumbing $ ,- - 2. Other Fees: $ 15- MENT
4.Mechanical (IWAC) $ List: B Jt{pl G OE':RT
5.Mechanical (Fire . . 1/S In
Suppression) $ Total All Fees:$ �^v`
�\ Check No. Check Amount: Cash o t: �("1
6.Total Project Cost: $ 4 , 6 eo u ❑Paid in Full l�Outstanding Balance ue: -u \v
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R I Restricted l&2 Family Dwelling
City/Town,State,ZIP IvI Masonry
RC Roofing Covering
• WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street —
Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(\'I.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes 0 No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
• SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
JO ((U r `fILC 3\\ )`k
Print Owner's or Auth ized Age s Nam ctronic Sinature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the RIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) I`[ Habitable room count
Number of fireplaces 1 Number of bedrooms 3
Number of bathrooms 1. `7 Number of half/baths
Type of heating system (3a5 SY(.Q4 ( J\.� Number of decks/porches oC
Type of cooling system Cu;, Enclosed Open
3. "Total Project Square Footage"may be substitutej,for"Total Project Cost"
a2.
....\ The Commonwealth of Massachusetts
-" ;—_ 1, Department ofIndustrial Accidents
Kiiiiiir 1 Congress Street, Suite 100
Oki Boston,MA 02114-2017
�., www.mass.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ✓ Please Print Legibly
Name (Business/Organization/Individual): Dili ` ,kk Ac:Af\ \�0. I(�(��
Address: 2)6 JQ �, °�+v
City/State/Zip: J t"V� Ro, Phone#: c9tl0''G b r �D-
' J Jb31
Are you an employer?Check the appropriate box: Type of project(required):
1.0 l am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling '
any capacity.[No workers'comp. insurance required.]
3.0 am a homeowner doing all work myself.(No workers'comp.insurance required.]t 9. ❑Demolition
l0 arbuilding addition ,- 'nA.0.. S pe ' .
4. 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
1
ensure that all contractors either have workers'compensation insurance or are sole l 1.Q Electrical repairs or additions
proprietors with no employees.
12. Pluiitbing repairs or additions b
5.0 I am a general contractor and!have hired the sub-contractors listed on the attached sheet. 13.(T "Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box fill must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify aide the pains and pert ii s of perjury tl the i iformation provided above is true and correct.
t 4 t
Sisnature: � �' -`�` \I i' te: l �
J'� I�C/ �' k 3 �. ]-
Phone#:,,.1 O�0 _t 0 }3J c90 �j— /.1. F- ,.: �j C.,
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License# •
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
oF'Y R TOWN OFYARMOUTH
BUILDING DEPARTMENT
�` � �^^ ,_�_4�^ 1146 Route 28,South Yarmouth,MA. 02664 508-398-2231 ext. 1261
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: ,�
JOB LOCATION:�hn 4 t 9 6fQ LAl' (�5-i,tf i � . -I n (l c . _b" Ct r jU xt44 k,
NAME STREET ADDRESS _ SECTIO OF TOWN
"HOMEOWNER" o ' i- \- - � '- 14551 dzi3 - ciqf:c g_735
NAME HO�PHON ``,_ WORE PHONE
PRESENT MAILING ADDRESS q i \ 1 r �-�0 KO, jty-ryto Ut- , frVki
CITY OR TOWN STATE ZIP CODE /
The current exemption for `Homeowner' was extended to include owner-occupied dwellings of one or two units
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that such
homeowner shall act as supervisor. (State Building Code Section 110 R5.1.3.1)
Definition of Homeowner:
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is or is intended to
be,a one or two family attached or detached structure assessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner;such"homeowner"shall
submit to the building official,on a form acceptable to the building official,that he/she shall be responsible for all
such work performed under the building permit. (Section 110 R5.1.3.1)
The undersigned `homeowner' assumes responsibility for compliance with the State Building Code and other
applicable codes,by-laws, rules and regulations.
The undersigned `homeowner' certifies that he/ she understands the Town of Yarmouth Building Department
minimum inspection procedures and requirements and that he / she will co ply with said procedures and
requirements.
HOMEOWNER"S SIGNATURE Au
L
APPROVAL OF BUILDING 01414 CIAL
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL
Ch.142. Yes No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
h:homeownrlicexemp
§TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 02664
508-398-22311 ext.-1261 Fax 508-398-0836
•
Office of the Building Commissioner
BUILDING DEPARTMENT
DEMOLITION DEBRIS DISPOSAL AFFIDAVIT
Pursuant to M.G.L. Ch. 40, §54 and 780 CMR- Section 105.3.1. #4.
I hereby certify that the debris resulting from the proposed work/demolition to be
conducted at 94) wAr-, 3ar 6 U 1
Work Address
Q
oat the followinglocation: (, 0 I ilk1--Gun(1. 01
Is to be disposed of ��
Said disposal site shall be a licensed solid waste facility as defined by M.G.L.
Ch. 111, §150A.
gnature I f Ap cation Date
f ✓
Permit No.
3/22/23, 10:57 AM Mail-Sears,Tim-Outlook
95 Wilfin Rd
Sears, Tim <tsears@yarmouth.ma.us>
Wed 3/22/2023 10:57 AM
To: maryitech@gmail.com <maryitech@gmail.com>
John,
I have reviewed your application and there are some items needed.
Conservation sign off
2.,iealth Department sign off
4k...
V. Water Department sign off4. Plans for rear deck expansion c i\\\ c.13k 11 ro_ ' -3
Please submit these items for review
This email is considered a written denial of your permit application per Section 105.3.1 of the
Massachusetts State Building Code. Section 105.3.2 states in part that "an application for a permit for
any proposed work shall be deemed to have been abandoned 180 days after the date of filing, unless
such application has been pursued in good faith"
You may appeal this denial to the Building Code Appeals Board in accordance with M.G.L. c. 143 §100,
within 45 days of this notice.
Timothy Sears CB0
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsears@yarmouth.ma.us
Timothy Sears CBO
Deputy Building Commissioner
Town of Yarmouth
508-398-2231 Ext. 1259
mailto:tsearsj'yarmouth.ma.us
https://outlook.office.com/mail/sentitems/id/AAQkADE3MDQ5NWZmLTkOYzItNDIwNi1 iMDQxLWNkMGQyNmE4NzE5NAAQAFoPhsiufSdNgJBTngtnG... 1/1
T
IV I
DEED REFERENCE ` ,
I E CERT. 195057 I a
a
in
RECORD OWNER *'4741 b
t JOHN & MARY BARRY � S
i �" 8 WEDGEWOOD COURT'
NEWTOWN: CT 06470
IIIP
-1- iONE � ISNORE eR•
ti
.� R-25 1 '�
-f, LOCATION NIAF
Assessors Map 34
Parcel 3
Area — 9,531 S.F.
WORK MU T CONFORM TO ALL JUN 3 U 2;22
WN BY S & REGULATI N
Zf, HEALTH D PT.
YAR OUTH WATER DEPT AT /��
i \\ s .
LOT 76 f/ LOT 75 \\`D-
, 9 6J f S.F. ,\
.r L �I
.' O.L. AC. v
i \ r
/// 1 EXISTING \ \ '�
- ` li `WOOD FRAME 1 C
l� • ` N4/95 E DEC.` PROPOSED °v i�
STE�—
STE a� Q
I DEC_ /i! //%/6ii (C\ (�� 1
__ _____- . .
0
r PROPOSED '__. .
�� S�
. .N ,, ADOiTiON : :4; 2c ST�E( EE \
�N CI
I;� v^Eyc. ��� w-�� o
` -IC� No.39398
2 l.V _ % �,%' DSl1q�1d
+-o I.UT .'4
11n r y,_ I , °G
496 FOREST' ROAD '
SOUTH YARMOUTH, MA. 02664
774-268-2035
CENT/RED P!OT PLAiV IN YARM,MO ITH, MA
i CERTIFY THAT THE BUILDING ON THIS LOT IS LOCATED AS SHOWN ABOVE
AND IS LOCATED ►v,THIN A HIGH FLOOD HAZARD AREA, ZONE All
COMMUNI;f—PANEL NUMBER 250015 0006 C, MAP REVISED JULY 17, 1986.
95 WiLFi;v ROAD SOUTH YARWOUI r;, MA j
PROJECT: 12-00 i j SCALE: 1 "= 30' I DATE: 10%31/16 j
, I , i AIN 0CA ( r2-) \ 21) I? o -3
Town of Yarmouth Conservation Office
10 ,�j ' bdirienzo(a�yarmouth.ma.us
Conservation Commission
Building Permit Sign-off Application
TO BE FILLED OUT BY BUILDING PERMIT APPLICANT:
Building Site Location: t�_J t,, ,}( i i !`i i ) �- �'rG�rm� _ C L. ;i
Map # .- ; i Lot(s) #
6 Property Owner: J Dk n °t<- (,,(��,t rallA Date filed: ._31)6( 0,.)23
*Applicant: )" G\V L 'k- �r- �(kAp f L,\
Applicant Address: '" t C kU 1 \c`\ n
i ' T s ( t✓ ` �)
��' - I -�J (_,
Email: I�� \ ;,,i, i �C- 'n ��� ��1�'��.��=1 � � 1 Telephone: �J ' � b
Please note:by subrylitting this appiica n,the)applicant grants permission to the Conservation Office to enter the location to conduct a site visit(if needed).
Proposed Project Description:
WU' • -L c'''IP(11) (-)i 1 UeCY- ( '-'''ftThk-A) (10 C.:V--• (-41),Z) Ci-f-''PACAl'ed kat CL'
k /1 (-) bb. AP C per- CA 043401 ate.
Site Plan Title/Date:
TO BE FILLED OUT BY CONSERVATION ADMINISTRATOR:
Does the proposed project require a permit? Y(a
Refer to: SE83- (or DOA permit"
Comments from Conservation Commission(pproved ) Conditionally Approved Rejected
e-e 5 -kli\ ? cv-\ '27J13t 1-"3
Conservation Commission Sign-off Signature: (2 077Date: 3 I Z 3 / 2 O 2 5
*TO APPLICANT:
All work-related debris shall be taken offsite or disposed in a legal upland location. At the end of each
day, the area shall be clean and no debris shall be in the Resource Area.
If work is permitted under an Order of Conditions, please arrange a pre-construction site visit with the
Conservation Administrator. At the time of site visit, the MassDEP File Number sign must be installed,
along with the erosion control/work-limit line. A copy of the Order of Conditions must remain on-site
during construction. Please refer to the Order of Conditions for further details.
Ira b 1 -1 I e •
firi WA-
TO\\ \ OF YAR'M OUTH
iN
< WATER DEPARTMENT
\ ,y 99 Buck Island Road
"'T^�"EEs� i�� West Yarmouth, MA 02673 -'I
�'` Telephone: (508) 771-7921 • Fax: t508i 771
ZZ
BUILDING PERMIT APPLICATION FOR
WATER DEPARTMENT SIGN OFF
TRANSMITTAL FORM
BUILDING SITE LOCATION: 95— GUI��r if v ,
PROPOSED WORK: X'� elc .6 Qc.k �
APPLICANT: �2dCiik
ADDRESS: / 4'
TELPHONE: SU F- - (.,?fa
RESIDENTIAL AND IOR COMMERCIAL BUILDING
Water Department: Determines Compliance of Water Availability and or existing location
Engineering Department: Determines Compliance for Parking and I)rainaix
Conservation Commission: Determines Compliance to Wetlands Act: i.e. If lot(s)border any type of
wetlands. streams, ponds,rivers, ocean. hogs, boys. marshland, ETC...
Ilealth Department: Determines Compliance to State and Town Regulations, i.e.
requirements for Septage Disposal and other Public Health Activites
Fire Department: Determines Compliance to State and Town Requirements for Personal
Safety, Property Protections, i.e. Smoke Detectors, Sprinkler Systems,etc
APPLICANT SIGNATURE 1) CF
OFFICE USE: COMMENTS ON PERMIT APPROVAL OR DENIAL.
7 ! z
RF:VIF,N 'D BY WATER DIVISION(SIGNATURE) DATE
E
-t:/c 3/z3 /2-3
Iv j I .
DEED REFERENCE41
6 CERT. 195057 a
It RECORD OWNER ?
/N D.
tI ! JOHN &� MARY RARRY /-cs- 5
II 8 WEDGEW000 COURT � •
t P.lEWTOWN CT 064.7n i
ZONE i look SAoRc biz.. .
J R __25 I jot'
•
LOCATIONMAP I
-I' Assessors Mop 34
I Parcel 3 Area 9,631 '•.F. _
WORK MU T CONFORM TO ALL JUN 3 U 2 22
ç
BREGULAI N \• 1 • HEALTHYUTH WATER DEPT AT ,l'\
f - c„_,
75 '- ;
LOT 76 ,-,� LOT D.-
r ,
/ �— 6. ` ��
i
i' \ �\-c \
c;l -' -9H WOOD EXISTING
i r 1
�� HOUSE i
#95 ‘ DEeK\ PROPOSED \
, ` I) STEP
I DECK t• ,_, ST£P
4
r ,,
-„, /..,,,,73,.0.
\-,:_„, ,,.,_ _______---- .
, ,„. ,,,._,_.....„--- 1
. I . I PROPOSED :: __ ���Ft OF .
m ; �O�TIOt�_ �� STEPH;8:11:nyI .4- FEy�. 1� 4-
MOOR `*�I itt,= 0 No.393 '
aG RV`el
i :i" _
74
496 FOREST ROAD
SOUTH YARMOUTH, MA 02664
774-268-2035
R-'F7ED PI OT PLAN I I/V YARN;�0i I u, M
LL r r r �� ! L I V r 1.r - D
1 CERTIFY THAT THE BUILDING ON THIS LOT IS LOCATED AS SHOWN ABOVE
AND IS LOCATED WTH1N A HIGH, FLOOD HAZARD AREA, ZONE All
COMMUNITY—PANEL NUMBER 250015 0006 C. '.P RE14SEO JULY 17 1086. I I
� I
95 WiLFi V ROAD SOUTH Y RWOU7i;, MA __I -
PROJECT: 12—00 i I St:,A'c_ -7 "= 30' I DATE: ;0/31/161
VW-
ris. ....
FE a
NAME 7 a 't 11
• 4-.9"64,„. r STREET ,_7-{/.-.. -C i_ -,-.1 ,C->-.),VILLAGE
/-
SERVICE NO.
METER NO. ' ;-- •-•b---....„4, /
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i
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N. _...... x
s:-
..% 1
X;
i I
/(, / /'':!:7
I
o -YAK TOWN OF YARMOUTHHEALTH DEPARTMENT
tz
• '-.,„ ` PERMIT APPLICATION SIGN OFF TRANSMITTAL SHEET
To be completed by Applicant:
Building Site Location: Ci5- W 1 ) ri r1 A d/rMWti pi,
Proposed improvement: (:{G1dIctime)( p o r ch -in.,/ k _41--
bitt G4 &e-e _
Applicant: ofbhn aI<C1 3e02 Tel. No.: `bb- `llv- A55tAddress: 4 5WI , .® ava' Date Filed:
**If you would like e-mail notification of sign off please provide e-mail address: F I-trad- 1eV a s C 1
� In �
Owner Name: it* '
C3a,
Owner Address: tc u,I \cl n ) 6 Owner Tel.No.: dzo--9 -C'3' /-15371_
aO3 - g-,353S
RESIDENTIAL AND/OR COMMERCIAL BUILDING
HEALTH DEPARTMENT: Determines Compliance to State and Town Regulations; i.e., Requirements
For Septage Disposal and other Public Health Activities.
EuY_NaD Please submit three (3) copies of plans, to include:
(1.) Site Plan showing existing buildings, water line location,
MAR 2.3 2023 and septic system location;
HEALTH DEPT. (2.) Floor plan labeling ALL rooms within building
(all existing and proposed) —
Note:Floor plans not required for decks, sheds, windows, roofing;
(3.) If necessary, Title 5 application signed by licensed installer
with fee.
REVIEWED BY: c' a 3 DATE: /J ,)�
PLEASE NOTE
vackC MMENTS/CONDITION :
s Cm r — cf edK rati-eCk
r
l
DEED REFERENCE i
i CERT. 195057 ca
A
ll RECORD OWNER I
t JOHN & MARY BARRY i ' !
I( 8 W.EDGEWIOOD COURT •
4 NEWTOWN, CT 06470 ,
ZONE sic
r/ O R-95 1 Sou
_ t
LOCATION MAP
I Assessors Mop 34
Parcel 3
Area — 9,631 S.F.
JUN 30 2022
•
HEALTH DEPT. \
LOT 76 ,,r- LOT 75
�-
{ .� `9,631 S.F. \
,�'`� 0.79 �:.0. ; )"
��
�^ — �k �z \ °
\ .
egg 1 y
{ DECK -'7 !'�si ';
Ir."' ///////, .,.% 't \
.- �y(N OF
4 -Ire
ico �
I, if---- \ 0 39R39E8
t V `O
p �L+v L.iif 74
1
SOUTH YARMOUTH, tiA 02664
774-268-2035
CERTIFIED PLOT PLr IV IN Y.4RMOUTH, MA
i CERITFY THAT THE BUILDING ON THIS LOT IS LOCATED AS SHOWN ABOVE
AND LS LOCATED WITHIN A HIGH FLOOD HAZARD ,AREA, ZONE A l l
COMMUNITY--PANEL NUMBER 250015 0006 C, MAP REl4SEO JULY 17 1986.
95 W1LFIN ROAD SOUTH YARWOUT I-I, MA
PROJECT: 12-001 I SCALE: 1 "= 30' I DATE: 10/3,/16i i
TOWN OF YARMOUTH
1146 Route 28, South Yarmouth, MA 2
508-398-2231 ext. Fax �-3 - 3
Office of the Building Commissioner
FINAL COST AFFIDAVIT FOR WORK IN FEMA FLOOD ZONE
To the Building Commissioner,
In accordance with 780 CMR Section 109 of the Massachusetts�State Bui�ing Code, the total estimatg
cost of
construction, including all related costs* of the building at q i j tin Rot .t ,D v fh a r" hi tand constructed reconst t�reconstructed, altered, repaired, or extended under building permit no. Sip __`, 3 -ate i gy mi
amounts to S 9loi`1a1l,o0 6L7_ 3 OU 51 (
I, Ma C • 6e )f ( ,being referred to as the owner/agent identified below,do solemnly
swear that the statements nade herein are strictly true,correct and made in good faith.
*Related construction costs include all work done with or concurrently with the work contemplated by the building
permit including construction, reconstruction, repairs. demolition, HVAC work, etc. Furnishings and portable
equipment are not part of the total construction costs.
+10,,,, p
Signatu 4 ow r/agent
u Ul - 33 4 03o
'rotary Public Signature 1'�4 Commission Expires
Notary Seal: ' R SARAN OSE K
4 Notary Public.Corru weatPINN of MNEY assachusetts
My Commission Expires August 23,2030
/ i/